Medicare Advantage Plans Must be Held Accountable AHA Says


The American Hospital Association (AHA) urged Congress to streamline Medicare Advantage plans’ prior authorization requirements in lengthy letter.

The AHA submitted a letter to the House Energy and Commerce Oversight and Investigations Subcommittee calling for greater congressional oversight to guard access to look after Medicare Advantage (MA) beneficiaries.

The letter urged Congress to support laws for the next:

  • Streamline MA plans’ prior authorization requirements
  • Prohibit MA plans from using more restrictive medical necessity and coverage criteria than traditional Medicare
  • Establish a provider grievance process and implement penalties for plans that fail to comply with federal rules
  • Make clear states’ role in MA plan oversight

“Inappropriate and excessive denials for prior authorization and coverage of medically vital services is a pervasive problem amongst certain plans within the MA program. This leads to delays in care, wasteful and potentially dangerous utilization of fail-first imaging and therapies, and other direct patient harms,” the AHA said.

“As well as, these practices add financial burden and strain on the health care system through inappropriate payment denials and increased staffing and technology costs to comply with plan requirements. Also they are a significant burden to the health care workforce and contribute to employee burnout.”

Thus far, the AHA refers to an advisory issued last month by Surgeon General Vivek Murthy, that notes that burdensome documentation requirements, including the amount of and requirements for prior authorization, are drivers of healthcare employee burnout.

Within the letter, the AHA also urges Congress to require MA plans to publicly report on standard performance metrics related to coverage denials, appeals, and grievances and for CMS to conduct more audits for plans with a history of inappropriate denials.

This latest letter from the AHA comes on the heels of last month’s request for CMS to take “swift motion” to carry MA plans accountable for inappropriately and illegally restricting beneficiary access to medically vital care.

Here, the AHA cited an OIG report that found that MA organizations often delay or deny services for medically vital care, even when prior authorization requests meet coverage rules.

A priority with the MA payment model is the potential incentive for organizations to disclaim services in an try and increase profits, the study said. As increasingly people enroll in MA, the problem of inappropriate prior authorization denials can have a widespread effect.

“Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically vital care and may burden providers,” the report said. “Although among the denials that we reviewed were ultimately reversed by the MA organizations, avoidable delays and additional steps create friction in this system and should create an administrative burden for beneficiaries, providers, and MA organizations.”


Amanda Norris is the Revenue Cycle Editor for HealthLeaders.


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